Forfeited Funds Claim Form

Forfeited Funds Claim Form
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
CINSF Membership Number
Address:
Residential Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Postal (if different from above)
Contacts:
Email Address
example@example.com
Phone Numbers (include country codes)
Format: (000) 000-0000.
Claim Info:
Date departed Cook Islands

MonthDayYear
Date
CINSF employee payment amount received on departure
Passport:
Passport Number
Country of Issue
Date of Expiry

MonthDayYear
Date
Billing Info:
Utility Provider Name eg Phone or Power company
Utility Account Number
Bank:
Name of Bank (include country)
Branch Location
Name of Account
Account Number
Swift Code
I hereby declare the information i have provided above is true and correct and that the documents submited with this application have not been alterted or created for the purposes of making a false claim.
SIGNED
DATE

MonthDayYear
Date
THE FOLLOWING DOCUMENTATION MUST BE SUBMITED BEFORE A CLAIM CAN BE STARTED:
- FULLY COMPLETED AND SIGNED CLAIM FORM
- CERTIFIED COPY OF ORIGINAL PASSPORT (INCLUDE DETAIL OF JUSTICE OF THE PEACE, SOLICITOR, OR COURT OFFICIAL)
- CERTIFIED COPY OF UTILITY OR ACCOUNT BILL (SHOWING YOUR NAME AND ADDRESS TO VERIFY YOUR DETAILS)
- CERTIFIED COPY OF BANK STATEMENT (THE ACCOUNT FUNDS ARE TO BE CREDITED TO)
Should be Empty: